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Posts Tagged ‘hormones’

“Return Decision Power to Women” on Hormone Replacement Therapy

Posted in Condition News, tagged , , , on May 15, 2013 | Leave a Comment »

It’s no wonder we’re confused. First it’s good; then it’s bad. Now it’s up to you.

Hormone replacement therapy has had more media makeovers than Liz Taylor, and it continues to grab attention here and there.

The latest, and highly credible, statement on the issue is from an international roundtable of medical experts convened by the Society for Women’s Health Research (SWHR). The purpose of this gathering of experts, which represented various specialties, such as cardiovascular disease, osteoporosis, and cancer, was to take yet another objective and rigorous look at the evidence regarding hormone replacement therapy, and to make recommendations as to its use and safety. The results of this discussion just came out in the Journal of Women’s Health.

This roundtable is a good effort to shed some objective light on the risks and benefits of an issue that’s been hotly debated for over ten years now, ever since the Women’s Health Initiative (WHI) prematurely ended its groundbreaking study of women receiving hormone therapy in 2002 because of a high incidence of breast cancer and cardiovascular complications.

The problem, however, is that hormone therapy (HT) is still the only effective, FDA-approved treatment for menopausal symptoms, such as hot flashes and vaginal changes. Recently two non-hormonal drugs were just nixed by an FDA advisory panel because they were viewed as ineffective.

Ever since the WHI results were released, the pendulum has been swinging wildly with each new medical release or research report. And while this latest SWHR roundtable really moves the chess pieces very little, it does solidly reaffirm positions held by the North American Menopause Society.

(In fact, NAMS had released its latest position statement on hormone treatment barely a month earlier.)

What the roundtable did add, however, is something I strongly advocate: Give women solid information about their treatment options and let them make informed decisions about their own health.

Their findings include:

  • In younger, postmenopausal women with menopausal symptoms, the benefits of HT outweigh the risks;
  • HT is the most effective treatment for osteoporosis and should be considered for the prevention of osteoporosis, especially among at risk women;
  • Contrary to popular misconceptions, HT for early, postmenopausal women does not increase the risk for coronary heart disease (CHD) and may even reduce it;
  • HT does not increase total mortality rates and may, in fact reduce them.

Here’s how the SWHR roundtable puts it: “It’s time to put HT back on the table so that women can discuss with their providers the option of symptom relief and possible long term health benefits.”

Amen to that.

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Q: Does my partner absorb any of my localized hormones?

Posted in Questions...and answers, tagged , , , on May 11, 2013 | 1 Comment »

Whether you’re using a cream, tablet, or ring to add localized hormones to your vagina, your partner is not absorbing any—no more than he did when you were producing your own hormones before menopause. You (and he!) can feel perfectly confident about your use of these products, and your intimacy will benefit from the increased comfort you’re likely to experience.

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Q: Why do I have a burning sensation?

Posted in Questions...and answers, tagged , , , on May 3, 2013 | Leave a Comment »

A burning sensation in the vaginal and vulvar area can be a symptom of vulvovaginal atrophy, which occurs as estrogen levels decline. Premarin cream or other localized estrogen can reverse those atrophic changes; it typically takes weeks of use for full effect.

If the burning sensation is in or extends further back, toward or including the buttocks, it’s likely not vulvovaginal atrophy. It could be, instead, a nerve condition. Shingles, unfortunately, can happen in this area; there are other pelvic floor conditions—like scarring or injury—that can affect nerves. A careful pelvic exam can help to determine exactly what’s happening.

I encourage you to talk to your health care provider—and again, if you’re not seeing improvement!

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Q: Will I miss my cervix if it’s part of a hysterectomy?

Posted in Questions...and answers, tagged , , on April 23, 2013 | Leave a Comment »

Most women have very normal sexual function without a cervix. I have seen reports that suggest an issue, but in 24 years of practice, I can’t recall a single woman who was impaired by the absence of her cervix.

There are complications that result if the cervix is left after a hysterectomy, including abnormal pap smears and continued bleeding. If there is any remaining endometrium (the membrane lining of the uterus) and you consider hormone therapy in menopause, you will need progesterone as well as estrogen. I’ve seen women less fond of progesterone than estrogen.

Whether you’re able to keep ovaries in a hysterectomy is a bigger issue to sexuality—and in fact overall health—for women. Even after menopause, the ovaries continue to produce hormones. Those hormones not only mitigate some of the effects of menopause, but they also promote bone and heart health. There are times when it’s appropriate to remove the ovaries as part of a hysterectomy, but the decision needs to be made based on each woman’s health and history.

Glad you’re thinking about your continued sexual health, and good luck with your recovery!

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So over Contraception? Think Again.

Posted in Condition News, tagged , , , on April 1, 2013 | 1 Comment »

Yeah, I know. You’ve been doing the contraception shuffle for, oh, decades now. Isn’t it “safe” yet? After all, you’re past 40. Maybe you’ve even missed a couple periods.

Not so fast.

You’re in the midst of a very hazardous crossing—those uncertain years between fertility and menopause during which you are less likely to get pregnant, but, make no mistake, you still can!

While women are indeed less fertile after 40, they absolutely can get pregnant. In fact, women can conceive even during perimenopause, when the menstrual cycle is beginning to become irregular.

For some reason, however, women seem to become more casual as they near the goalposts. How else to account for the fact that women over 40 are the least likely to use birth control of any age group, and that their abortion rates are as high those of adolescents, according to a 2008 USA Today article.

In Great Britain, women in their 40s are now called “the Sex and the City generation,” and they, too, have grown careless. In the UK, abortions within the over-40 age group have risen by one-third in the past decade. In the US, 38 percent of pregnancies in women age 40 and older are unplanned. Of those, 56 percent end in abortion, according to this article in HealthyWomen.org.

By the time they reach 40, women are generally old hands at birth control. But at this point in life some reevaluation may be in order. Levels of fertility are decreasing, and hormonal levels are (or soon will be) in flux. Some women may not want to have children; others may want to keep the option open. In any case, an unplanned surprise complicates life really fast.

This is a good time for a conversation about birth control with your healthcare provider, and you may have to initiate it. While you have more options than ever, the best one for you might be different than what worked for you in your 20s.

And just so you know, current guidelines advise that you remain on birth control until one year after your last period, the official definition of menopause. Complicating the picture is the fact that with hormonal forms of birth control, such as the pill, your cycles may be irregular or may stop completely, which masks the onset of menopause. And the withdrawal bleed during the week off the pill isn’t considered a true period.

Birth control after 40 falls into several categories: permanent, long-term or short, hormonal or barrier method. They vary in levels of effectiveness and in the side effects you may experience. And remember that condoms are the only type of birth control that protects against sexually transmitted infections.

Probably your most immediate decision is whether to end childbearing permanently. Tubal ligation is a laparoscopic procedure that happens under general anesthetic in a hospital. There’s also a new, non-surgical option that a doctor can do with a local anesthetic right in the office.  Or, of course, your partner could have permanent sterilization as an outpatient office procedure.

Hormonal types of birth control are very effective, but can have both side effects (bloating, risk of stroke for some women) as well as protective benefits (against bone loss and some forms of cancer, for example).  It is very important to carefully review your health history with your health care provider to select the best option for you.

Short-term hormonal options include

  • Combined estrogen-progestogen pill (COCP). This is “the pill” you are probably familiar with. Since it now has very low estrogen levels, it’s considered safe for women who have no risk factors until age 55.
  • Progestogen-only pill (POP), which is a good option for older women. It must be taken regularly at the same time of day, however.

Long-term hormonal options include

  • Progestogen shot, which is a once-every-8-12-week option.
  • Progestogen implant, in which a tiny rod is inserted in the upper arm. It lasts for three years.
  • Vaginal rings release low dosages of estrogen. The ring is kept in the vagina for three weeks, then removed for a week.
  • A patch, which also releases low dosages of estrogen and progestogen.
  • An IUD impregnated with progestogen, which is highly effective and lasts for years.

The old non-hormonal standbys still include

  • Condom. Again, the only birth control that also protects against STIs.
  • Non-hormonal IUD. Also highly effective and long-lasting.
  • Diaphragm with spermicide, cervical cap, or spermicidal sponge.

Your choice of birth control at this point should be informed and careful. You need a plan to carry you through menopause, and you need to begin the dialog with your healthcare provider.

Since the consequences of ignoring the issue are so life-changing, this conversation ought to begin now!

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Q: Why did I orgasm while breastfeeding?

Posted in Questions...and answers, tagged , , on March 25, 2013 | 1 Comment »

Remember oxytocin? It’s a hormone that facilitated the let-down of milk when you were nursing, and it’s released with nipple stimulation. Oxytocin also stimulates contractions for the uterus (which is why any of you who had labor induced might recognize oxytocin by another name: pitocin). Outside of childbearing, oxytocin works with other sex hormones to facilitate orgasm and increase the intensity of pelvic floor muscles. Oxytocin levels have also been noted to fluctuate  throughout menstrual cycles, correlating with lubrication.

This is a hormone that has lots of favorable effects on sex! There has been research in using it to enhance sexual function, but there’s not a product readily available yet. Stay tuned!

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Too Tired for Sex? Join the Club

Posted in Condition News, tagged , , , on March 11, 2013 | 1 Comment »

I was sitting in a tiny hut in Mexico talking with a dignified older gentleman. Outside the ramshackle house, the sun shone on the empty desert. The ocean lapped the nearby shore. There was no traffic, no noise, no shops, no phones.

“The Americans, the Germans, and the Japanese are the hardest-working people in the world,” the man said.

First, I was startled that someone in this very remote place would be so astute. Then I wondered: Is this a good thing?

With all our mobile toys, we don’t ever have to stop working in America. We can be connected 24/7. Maybe we can squeeze in a few extra obligations after-hours. Or, we might be caring for parents and children, and sometimes spouses and grandchildren. Even if we’re retired, we’re programmed to run hard and fast.

But look what it’s doing to us. We’re stressed; we’re overweight; and we’re dog-tired.

Sex life? What sex life?

Ian Kerner, a well-known sex therapist, cites a recent study by the National Sleep Foundation in which one-quarter of American couples say they’re often too tired for sex.

Mary Jo Rapini, one of our medical advisors, recalls encouraging a couple to take time for a romantic getaway. “Oh no, who’ll plan that for us?” they asked. Well, “usually the couple enjoys planning these things together,” she said.

“We don’t have the energy,” they responded.

Think of sex as the canary in the coal mine. It’s one of the first things to go when life gets out of whack. But if you ignore that quiet little loss, pretty soon the bigger stuff suffers, like good health and relationships.

If sex is just another obligation, or you’re too tired to even think about it, you need a life/work balance adjustment.

If you don’t have some other physical or psychological problem, such as a thyroid condition, chronic fatigue syndrome, serious relationship issues, or hormonal imbalance, you shouldn’t be too tired for sex.

So, if stress, overwork, overcommitment, and the general pace of life, has killed your libido, consider this:

Allow time for sleep. Right now. Nothing else matters if you’re chronically sleep-deprived. Re-assess your involvements. Try to delegate tasks. Cut back on work. (Doctor’s orders.)

“A good night’s sleep every night—more so than exercise and a healthy diet—keeps our sexual engines humming,” says Barry McCarthy, PhD, a Washington, D.C., sex therapist.

Give yourself an hour to unwind before going to bed in the evening. Turn off the TV and all the other screens. “It’s terrible to have a television in your bedroom, which should just be for intimacy and sleep,” says sex therapist Sherri Winston.

Spend that time relaxing with a book. Share a cup of herbal tea. Cuddle with your honey. Take a bath.

Exercise.  Regular, moderate exercise is part of the work/life balance thing. Can you walk 30 minutes a day? Maybe with your partner? Can you find a gentle workout video? (My favorite now is hot yoga, but I have friends who spend 20 minutes a day with our old pal Jane Fonda.)

Exercise makes you feel better. It helps you lose weight.

And guess what? It helps you sleep better.

De-stress. Yeah, I know this sounds impossible. But you have a choice: You can continue to worship at the altar of overcommitment, at which you will offer up your health, your intimate relationships, and your quality of life.

Or you can bring your life into a healthy balance, and probably live longer—and have a lot more satisfying sex.

Need more persuading? Stress releases cortisol, a hormone that decreases testosterone, of which we women have precious little in the first place. Thus, stress directly hammers our sex drive even before the sleep-deprivation sets in.

Follow your rhythms. If you’re exhausted at night, why not have a little afternoon delight? Or maybe sex in the morning? Testosterone levels naturally rise a little then, so that might be the opportune moment to turn up the heat. Caress and cuddle at night and save the sizzle for the morning.

Just do it. You know how you may not be in the mood, but a little nibble on the ear, a little stroke on the thigh… and, well,… maybe…

Libido is like a puppy. Give it some loving, and it will follow you home. And sex begets more sex. You have to do it to want it.

When I recall the tranquility I felt in that simple hut in Mexico, I wonder if we somehow took a detour on the road to the good life. Maybe we can learn something about simplifying, cutting back, enjoying the little things, and loving each other from people who don’t have many possessions, but who probably sleep very well at night.

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Q: What should I know about Estrace?

Posted in Questions...and answers, tagged , , , , on February 7, 2013 |

Estrace is a bio-identical form of estradiol, a plant-based version of the same estrogen made by our ovaries. It comes in two forms—oral (systemic) and vaginal (localized). I use very little oral estrogen in my practice, because we’ve learned that transdermal estrogen (delivered by patch, gel, or spray or other forms that deliver it through the skin) is safer than oral. Because it’s not metabolized by the liver, it doesn’t carry the same risk of thrombosis.

Vaginal Estrace is great from a therapeutic perspective—that is, it’s very effective for treating vaginal atrophy. Because it’s a cream, though, many of my patients don’t love it: Some find creams messy to apply. It’s important to find a form of localized hormones that each patient will actually use!

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New VA Treatments in the Pipeline

Posted in Condition News, tagged , , , , on October 18, 2012 |

Sometimes we medical people get to hear about medications and treatments before they hit the doctor’s offices and pharmacies. Recently, MiddlesexMD advisor Dr. Michael Krychman interviewed Dr. James Simon, a well-connected expert in women’s sexual health, about new treatments that are under development to treat vulvovaginal atrophy (VA).

If you recall, VA is the thinning and inflammation of your delicate genital tissues, including the vagina, which is caused by loss of estrogen after menopause. As you can imagine (or already know), it causes genital irritation, an increase in minor infections, and uncomfortable—or downright painful—sex.

VA doesn’t go away, and it doesn’t get better by itself—it requires treatment, usually in the form of estrogen, whether taken internally or applied topically. Topical estrogen creams, tablets, and rings can be very effective in treating the effects of VA.

But a few new approaches are also under investigation. They are:

  • DHEA suppositories. DHEA (which, if you must know, stands for dehydroepiandrosterone), is a steroid that, according to Dr. Simon, is “taken up by the vaginal cells themselves, which convert them to testosterone and estradiol.” The estradiol eases symptoms of VA, and the testosterone improves muscular function and makes the vagina and clitoris more sensitive, so it also gives the libido a little boost. None of it is absorbed into the system, so the medication should be safe for women with breast or ovarian cancers. Don’t expect to see this little number on pharma shelves too soon. Dr. Simon advises patience, since the treatment in still in clinical trials and then must be approved by the FDA.
  • Treatment for VA in pill form. Because many women (and their partners) find topical treatments for VA—creams, rings, suppositories—messy, unpleasant, and a sex inhibitor, a new drug that is readily absorbed by the estrogen receptors in the vagina, but not in other places, such as the endometrium, is being tested.
  • Very low-dose estrogen tablet. In an ongoing effort to find the lowest effective dose of estrogen, Novo Nordisk, the manufacturer of Vagifem, recently found that 10 micrograms is effective in treating symptoms of VA. “It seems to work extremely well, even at these extraordinarily low doses,” said Dr. Simon. And even after taking it for a year, he points out, this dosage amounts to just over 1 gram of estrogen, an amount that is probably safe even for breast cancer patients. The disadvantage, warns Dr. Simon, is that, while the medication treats vaginal symptons well, it might not be as effective for the vulva (the external genitalia). In this case, women may still need an estrogen cream for the very important vulvar care.

Since over 40 percent of post-menopausal women experience symptoms of VA, an effective treatment that doesn’t increase our cancer risks would make us—and our partners—very happy. Take heart. “Many companies are dedicated to innovative treatments without rise in systemic hormones,” said Dr. Krychman.

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The Stages of Menopause

Posted in Condition News, tagged , , , on September 17, 2012 |

Last week I wrote about the STRAW guidelines and STRAW + 10, an update based on the review of research done in the 10 years since the original guidelines were published. Because not all of us have reached menopause, defined as one year without menstruating, some of us are interested in what we can learn from the detailed phases!

For context, remember that STRAW draws three large phases: reproductive, menopausal transition, and post-menopausal. The recent review and enhancement of the model outlined four specific stages within that “menopausal transition” that has many of us looking for answers.

During Late Reproductive Years, your ability to have a child is declining. Your menstrual cycles may be shorter and either lighter or heavier. During the first week of your cycle, the follicle-stimulating hormone may rise more than before as your body works to continue reproduction. The length of this stage varies a lot, but it could be as much as nine years.

Perimenopause officially begins with the second stage, Early Menopausal Transition. During this stage, you’ll see more unpredictability in your menstrual cycle—you may even think it’s not predictable at all! And because your body is producing more estrogen but less progesterone, you may see an increase in PMS symptoms like irritability and bloating. This stage can last four years or longer.

Late Menopausal Transition is the second “half” of perimenopause (I put “half” in quote marks because it’s probably shorter than the first stage—a year up to a couple of years). This is when you’re likely to experience the “typical” symptoms associated with menopause: hot flashes, difficulty sleeping, and mood changes. You may not have a period for a couple of months. At this point, the big trend line for hormones is a decline, but both estrogen and progesterone production can vary wildly from day to day.

Finally, you reach Early Postmenopause. Again, this is marked by a full year without a period. If you haven’t already experienced hot flashes and other menopausal symptoms, you may now, or they may be worse for a while. Because estrogen and progesterone levels are very low, this is when other symptoms become apparent, like vaginal dryness or thinning of vaginal tissues.

As I’ve said before, there’s no clear roadmap that’s infallible for every one of us. I understand, though, the desire to understand what’s happening and to try to predict what lies ahead. I have a friend who’s 56 and still, by the STRAW + 10 stage definition, in “late reproductive years”; by the guidelines, she could be 69 before she reaches menopause. Can that be true? My medical equipment doesn’t include a crystal ball!

But not having a precise roadmap doesn’t change my recommendation to all of us: Learn about what lies ahead, whether it happens fast or slow, early or late. Do what you can to compensate for or manage the changes in your body as you’re aware of them, just as you pick up your reading glasses more often when the menus are hard to read. And, because it’s true that as hormones decline, we “use it or lose it,” stay as sexually active as you choose to be. It’s good for your health, it’s good for your relationship, and it’s good for your self-image.

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